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HomeMy WebLinkAboutBuilding Permit #249-2012 - 154 MAIN STREET 9/26/2011 TOWN OF NORTH ANDOVER . APPLICATION FOR PLAN EXAMINATION Permit NO: _aa 2 Date Received Date issued: 4 4� / ORTANT:Apphcant must complete all items on this page LOCATION 1 Sy t�!n 1!9:%vN s� Print PROPERTY OWNER A v%AeaA c-^ Print "NO: C>1,c�P CEL:yoi l ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑Industrial C(Alteration No. of units: ,,Commercial "epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition -- ❑Other -- _- - - - - cx.-,F.�zc'a-< ___ ----�____. 'r•S "�—_ti 2` .���J�r1`iic— �.BEY y7. .tis: e: -t_� _...: .....,� . - - -_�,'�`��`:__• e � p��Tood-lain ., ;pkWetlands�;" 'r. �:; ;�t , 'iWateishecl�Dstret' . t 'r DES CE 1 T ION 0Fn WORK TO EL P E R i0_s ED: PIZJVIdC ,e,an 7AQk -...0 IGAw.,R Llccts5 17� vt�J`S �.n� ���'Krnt, Zr- Cos 7b,1A c e-5 (Identification Please Type or Print Clearly) OWNER: Name: "i3�.a\� o+- �4r�. � c Phone: -7 335 -i;L l s:- Address: Address: 1 S`I Mme;^ ST• CONTRACTOR Name: ne: -78►- ass-Li,;v7 S ��� �� Address: 113 So �Pti,n �� , IAA. 02-i q 0 Supervisor's Construction License: p51 1 0 3 Exp. Date: -1 - aca- -2- Home Home Improvement License: Exp. Date: ARCHITECT/ENGINEER ri-e-nsl c >Z Phone:_ q 612 - 5700 am c . % Address: � MAj4_ Reg. No. 1 b 3--3 FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F: Total Project Coat: $_' -crc5� ��.�y 7 FEE: $ -5 Check No.: ;26 Receipt No.: a y f 2 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund -f tip—,'=--- - �' - i' - - =Si" nafure.of:`co' - er_._ - :�F:r_ ' ritracfor:.: - , zStgnafiare:',of�Agei��Own. 9_,?=,�--------_=--=_--- I Plans Submitted ❑/ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swum ing Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF-U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT' ❑ ❑ COMMENTS CONSERVATION Reviewed on Si mature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/recelpt submitted yes Planning Board-Decision: Comments Conservation Decision: Comments Water& Sevier Connection/Signature&Date Driveway Permit F DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT -Temp Dumpster on site yes no Located at 124 Main.Street Fire Department signature/date COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: _ ELECTRICAL: Movement of ltfieter location, toast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA-- For department use • f ® Notified for pickup - Date Doc:.Building Permit Revised 2008mi Building Department The following is a list of the required forms to be fined out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits e Building Permit Application ❑ 1P.16-kers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products MOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit, Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of C°or rtr-ac ❑ Eloor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses .❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (if Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: - issuance of Bldg .Permit . �iit dumpster permits require sign oft from Fire Department prior to is In all cases if a variance or special permit was required the Town CIerks office must stamp.the decision from.the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: Doc.BulldingPermit Revised 2008mi. 1 Location No. t /1- �D Date t 01 Y d gO*TN TOWN OF NORTH ANDOVER 0 . p � s Certificate of Occupancy $ cMusE<� Building/Frame Permit Fee $ ffi Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # �© t 24612 Building Inspector NORTH To'"M Of o , '� dover, MassLAKE ., �A COCMICHEWICK\yet O'4ATED � 7�7 ` BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System fir. .....:.................................................................. FoundaA. tion BUILDING INSPECTOR n THIS CERTIFIES THAT........... .17 ,1��.......��............./..../Yl�Jc� ... has permission to erect........................................ buildings on .. '1 . %v... r ............................................. Rough to be occupied as............... .:/ ...... ........ .F ...., ? lll, :.......:................... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration'and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIO STARTS Rough ��..... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. i i CB Richard Ellis, Inc. AM In Bank of America Account 1025 Main Street C9 RICHARD ELLIS Waltham, MA 02152 www.ckre.com ioson.ricker(R)cbre.com 401.447.2677 Direct Transmit-Cal To: North Andover Building Department CC: Mike Holland From: 7ason flicker Re: Bank of America— 154 Main St. Date: 9/1912011 i As requested X For your review 0 For your approval For your use 0 For your information Notes: To Whom It May Concern: Please allow Mike Holland of Holland Construction to submit for permit on behalf of CBRE and the Bank of America. The plans being submitted should be dated 8/1/11 from Gensler&Stonefield Engineering. Based on the contractors Schedule of Values, the estimated cost of this project will be$116,547. Please do not hesitate to contact me with any questions or concerns. Thank you, son Ricker Project Manager 1 Exhibit G SCHEDULE OF VALUES Note:TNS Sehsdit Of Vai-form OW be u11bnbed by Olu CaOcbr In aocadY Wel Sectb14.4.1 oftha AOWWC TNa SOV form to a summMim of Olu ctW bit wdYd by dY GC for ifb work d~.Any 0-aa*mftreot kckoded by ft GC%erly aubcaSr.Ws Nd MWl be w-nI1 the ar.hbWd'GC AMaw W.A eddHorW Db%IuW aubWa4a mut m edfd mat hm 6Wapprpl%ba MadNFamuf 2004 code fated.Cod.mey W rucked fmm O to*m The CSI uN cWk dMsbn ax%,aluV wM the SuEeafruem/Corfradw Name and Work de Wa.Mabe-cored 0 ft Pry AppicaWn(3703 CafbWbl Sheet. General Contractor/Supplier Name: M.Holland&Sons Construction,Inc. ao.n<Mco b,am sappk,MfD7 CW Project Number: Project Name: 154 Main St.-North Andover-ADA Facility Partner Work Authorization#: Contract/Master Service Agreement Number: LSPMHOLL20100501.O.0 LSP or GMP: LSP Estimated Project Duration(weeks): 3 TaW CansnWcn Dort $ 109,436.00 $ 903.00 Genual Comrx OH 8 Pro01(enlm%) 3.60% .$ 3,830.19 S Ad WstratNeGeromlC6nd (emer%) -- 3.00% S 3,283.02 S - GrarW T9kl Project Cost -3 11a,647,21 Enter SOV version here(n S"Planning/Re-Construction SOV","Original + - - Construction SOV","Change Order#1 SOV") Tabl Saks Tax Y f f03.1- Obverse Suppliar Spend(DSS)f-dy MSD% 96,60.0 r 6.03% a d ': ,: •j^ ., .' ... ,• �°'�""•Sifu"iY•Y.f�ii6"' .:a.. ,QC1•r."SGS ' �1$d�r�` 01.31.00 Men • WY t b 3 6./50.1 S 8450.1 3 f_ _a,K0.00. Scbadukd 7'd9ra9ab WasWhy Rale for Project Gerlarsl O1.J1.W LOMiksns-Wapss ban Ebibk L-2.0(GMP) 3 cab $ 01./123 lIN 61m Faw 0 b $ 01./1.26 aelldl Parmib Foe 1 LS S 121.W S 1,YJ0.1 S f s S 1,3300 01.45.16 Cu Ifty Cabd dust Fadlikes 1 b S 6,570.00 S 6,570.00 S 170.0 3 170.00 S f_ ___6740.p 110LLM1D CONST 01.452)Twmib PrvlaU4n/PM Colmd 0 b 3 3 S S S S _ 01.51.00 Tampon U61i6w 0 b 3 S S - S 0152.13 FbM 06b 0 b $ S S S S S 01.52.16 n.Ah 6 Sally FadlN--Aw 0 b $ 3 - $ 01.52_16 Tam Bamrooms 0 b $ $ 01.55.28 Tm6k Cerkd 0 Is $ S S $ S f 01.5800 Tam -d-Encbsunf 0 b $ S S 3 6167.99 TamersgCorkda-EnWmn I 0 b $ S S 3 3 f_ O15E.W ProjM kknk6mtlon-GC CanWuctlon5 0 b S S - S $ 3 f Ott II.0 C-I B West Me 1 LS S 5,390.1 $ 53W W 3 1,290.0 S 1,260.0 3 12.00 f 6692.00 01.89.01 D6mr-EP.. 0 b 01.89.02 dMr-E In 0 h S S $ $ $ 3 __ 01.86.1 01M- 0 b $ S 3 $ $ f 01.54.13 Tem EMvabm 0 b $ $ 3 f S $ 0154.16 Tam Ilolsh 0 b $ $ - S f_ 0154.16 Tam 0 h S $ - S - f 5 f 0156.23 Tam m Scslfddirq erd Fadorms 0 h $ s - S - f $ f _ 01.5628 Tampanry 5Wrp a mi 0 h $ S - S - S $ f 01.76.W Clmena Subniaah 0 h i S i f S f my 10- 02.41.12 Eke Demolfbn(Cawrete PoW ate 1 LS $ 5,670W $ 5.670.W $ 4310.W $ 4,310.1 $ 78.W $ _ 100W.W $ 24W.00 RJ WM saw culaM eemomeabdn9cmcreN arM erica 02.61.18 Bjildinp_Demd (S-m) 1 LS S 3120W S ],1201 $ 2.1W.W $ 2,1W.W $ W.W f 6 66.0 HOLLANDCONSTtlem`W pian 0].81.1 Removd 6 Dh 1 COIHaminabd M-1 0 Is $ $ $ $ Sf 0253_1 Emironmaribl Adnshe A.kma 0 h $ $ $ $ - $ - 0].651 Moa RamWhtlon 0 h S $ $ $ 02389.01 O1Mr- In 0 h S S 3 f S S_ 02.89.02 Omw- in 0 b S $ $ f $ $ 1.11.0 CancrM Faml ouMatbn! 0 b S f $ 120.1 CwcM RN 0 b S f S S S S___ __ 03.W.1 CM4n4'bw Concrtla 6hks 0 h 3 f S - S S - f _ We9.o1 ATM c4mlw. 0 1 $ 3 s - $ 1.99.02 E Faurgatlons 0 b 3 S S $ 03.99.1 Carlcnb BOlbNa 1 LS $ 1,12nW Ali" S 120.1 S 120.W S 45.1 f 1 .W 1-1110dbrda as per Wnk sbmbrtl SIM 04.20.1 Unk Mawr / LS S 12W.W $ 121.W 3 2W.W $ 21.1 3 f_-_ty4600 ___ NOLIAND CONST Repaln roexis8rq 04.9901 qhx-E In 0 h S $ $ $ 3 { 04.96.02 Olhm-E h 0 b S $ $ $ 3 f 05Sukal Sel Fmi.12 $ 0411 Me6Nd Fml 0 3 f $ 3 f _ 3 f 0552.W Mehl Raili 1 LS $ 32451 f 3 45.1 S /,1201 $ 411 3 f_ 7311 Ramos kon Railirq at rampart sbirl 05.66.01 U--Sbd 0 h S S S S 3 f _ 05.99.02 Mehl Well Por,eh IsvabrL or KMCMn 0 b 3 $ S S 3 $ Pepe 1 dorm Algav-ADA Project Name: 154 Main St.-North Andover-ADA Facility Partner Work Authorization#: Contracti'Master Service Agreement Number: . .. . . ILSP or GMP: LSP Estimated Project Duration(weeks): 3 1 230DO $ 2XlW IO,W $ 70,M® OO®®®®®$_ oz O ®®®®®_ DIVISION]:TNERMPLR MOISTURE PROTEOTIONv� 0 0' 0®®®®® ®" O ®® $ ........... '®'" - , 0' 0®®®®® fix......-_— '®:' ... 0' 1, S $ $ $ ...0°l. OIVI91ON O:OPENNGS :.".:- ..'..:..�:x�- ru .� ,., •.:....:. :::.s:-, _....; ..,,.:..'.:' ta.'...'.-- .: � .:-c.z�:.^a.'.:^:-t'.:-.; 0 om®®®®® ox - --.. _.. yyDI���I••�V��IS��I0rN��9:FINISHES �:• � ". -�.'r� - •-» :: "-- '.-- �-� - �. -: .�- ...,..,- FS t0d5800� 10% 1 -t%'-` ��--'<.+ ._. - ® ami®210.W $ 2M.W $ 2W.W 70.00 ——3% ' oo®® :: ®®® oo®®®®®�__-- -- _ DIVISION I0:SPECIPLTiES .: .... .:. .........:.. ':.. ...,. ...,..•�': ...;:'... t,,. ,...-.�.. ...-.;,�. i .�;.».... ....�:-.3.5..,...,. - �� 0%-..._-I .n v+Mu✓.e,r'i�:�•-KH' . 01. ®®® $ OX 1�1 Lmkm01. ®®®®® 01' ®®® $ ® __... 1 01. ®®® 0%-_-- 7 II:EOUIP6:ENi .. 0/ M!Minn 0_ _ i Project Name: 154 Main St.-North Andover-ADA Facility Partner Work Authorization M ContractiMaster Service Agreement Number: . .05 . LSP or GMP: LSP Estimated Project Duration(weeks): 3 DiVI5ON 3]:TELECOMMUNOATIONS .,. ...... .._..... ._T_-_ r - -- .. � ,5 I__--__O�R_..._I _. � ••: 1. 04 DVSON 26 E iRONC 6AFETYA SECURITY-" r ".., � , r' i .��•+ +. ��' "• `++•- ': t-�", '^ • -.1-5 0°/. I T ®"' 0' ©®®®®® 4 DVSON 3,:EARTHWORK -...-, .. .. ,. �.•...�.s............. .. a.:. ,..-T✓ '.^.tA+ .f 6. � ._ OX I � }.:. - 31.10.W Sft 0o $ 3 $ OX • ® DIVISION 33:EXTERIOR IMPROVEMENTS .. , '--• :..�...,'..�..�__...._>.:.e-.... _..: .;'.,..: ,x..i,' v .:,.:...�.1.5 .-...J6 Ba6.00 1 JS% I _s• ,._. .i.1,:.:; :..: ..-... .,�.::_:..-I. U.12.16 ApW °° °. :°°° .°°r IMM t34 -- ® ....- 0' 0®®®®® ® om�oo� ®A70.M® -- - - UA TM om $ �M ® - —-- swppim • oo®®®®® --°---- o �.00 ® � HO ocmsT 00®®®®® _ OX �....�,..:,.,y...,w.,:.M......,�,.....,aY.:.q,.w.t c�.•+3.^+T:'rT.6.......o .. I OX 1. ....m., ,.. '�^'...Tar--,...rp.....:�.: .s I...S.:..: m 00®®®®® 0% _- OX .. oo ®®® _. ._... GG ALLOW4NOESantl:or OTHER SPEC ALTIES�`-:'. ",. .. _:. =•.,-t- <� ��,:.� mev -. - ..... xi ,• .,; ^:a6 � - 0:4 1 +'} T" 0 O0®®®®® Om®®®®®© 0 0©®®®®®®_—_ox OO®®® $ $ $ ov - 01,21M 1 • om®®®®® om®®®®® • om®®®®® • 00®®®®® ---°��—� Ao GONi1NGENOT Ab Al.Holkind&Soe;Construction,Inc. ape M.HOLLAND&SONS CONSTRUCTION,INC. MICHAEL HOLLAND 1126 MAIN STREET,WEYMOUTH,MA 02190 Dengn&Constmction TEL 781 335 4275 FAX 781 340 0077 CELL 781 953 1752 mike.holIand@thehollandcompanies.com THEHOLLANDCOMPANIES.COM AT HoLtand Sons Comtraction,Int. A� CERTIFICATE OF LIABILITY INSURANCEF3/29/ D IDD/YYYY) 2011 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Gail Paling g Risk Strategies Company PHONE , (781)966-4400 ac No:(781)963-4620 15 Pacella Park Drive E-MAIL alin @risk-strategies.com ADDRESS:gP g Suite 240 PRODUCER_US ERID00001560 Randolph MA 02368 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A NGM Insurance Com an INSURER B National Union Fire Ins Co 19445 M Holland & Sons Construction Inc. INSURER C: 1126 Main Street INSURER D: INSURER E Weymouth MA 02190 INSURER F: COVERAGES CERTIFICATE NUMBER:CL111433967 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR I TYPE OF INSURANCE ADD R POLICY EFF POLICY EXP LTR INSR WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 -13A—m—A-GE-TO RENTED X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ 500,000 A CLAIMS-MADE Fx_]OCCUR KPB0820S 1/3/2011 1/3/2012 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY X PEO-- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 ANY AUTO (Ea accident) A ALL OWNED AUTOS 1B0820S 1/3/2011 1/3/2012 BODILY INJURY(Per person) $ X SCHEDULED AUTOS BODILY INJURY(Per accident) $ PROPERTY DAMAGE X HIRED AUTOS (Per accident) $ X NON-OWNED AUTOS Medical payments $ 5,000 Underinsured motorist BI split $ 50,000 X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 5,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ 0 DEDUCTIBLE $ A X RETENTION $ 10,000 UB0820S 1/3/2011 /3/2012 $ B WORKERS COMPENSATIONWC STATU- OTH- AND EMPLOYERS'LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? ❑ N I A 500,000 (Mandatory In NH) KC004303361 1/3/2011 1/3/2012 CRIPTION OF OPERATIONS below E.L.DISEASE-EA EMPLOYE $ 500,000 If yes,describe under E.L.DISEASE-POLICY LIMIT $ 500 000 DES DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space Is required) Issued as evidence of insurance CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 1% THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN For Infomation ACCORDANCE WITH THE POLICY PROVISIONS. Only AUTHORIZED REPRESENTATIVE Michael Christian/GZ ' ACORD 25(2009/09) ©1988-2009 ACORD CORPORATION. All rights reserved. INS025(200909) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: 11;Lb c-c-S— City/State/Zip: �e.�{Nt,�J-71/x H A Phone #: -7 S 1• " •y;L Are you an employer?Check the appropriate box: Type of project(required): 1.54-4 am a employer with *7-S 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 1 7. remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp.insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their ]0.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.]f employees. [No workers' 13.0 Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: V4 A-Tt c.'►-4,A 4A 'F.;r -V+4S C„o Policy#or Self-ins.Lic.#: \14 L m y X03 3 r. 1 Expiration Date: I • 3 • 2.of 2. Job Site Address: 1511 "AZ n 3T City/State/Zip:U,&&.l()du Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: %i Phone#: ���• 33S• �i�� s� Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: , North Andover, MA �EFlED ARC CONSTRUCTION CONTROL Q`��\���VA r. FsT PROJECT NUMBER: 12.7707.081 Y� No.10373 rn MARBLEHEAD ;'D PROJECT TITLE: Bank of America ADA Survey MASSACH SETTS ?'o PROJECT LOCATION: North Andover, MAq�� MPssP ADDRESS OF BUILDING: 154 Main Street, North Andover, MA NATURE OF PROJECT: Minor Interior Renovation for ADA upgrades In accordance with section 116.0 of the Massachusetts State Building Code, I, Kenneth I. Fisher, AIA Registration No. 10373, being a registered professional architect hereby represent that I have prepared or directly supervised the preparation of all design plans, computations and specifications concerning: Entire Project Architectural X Structural Mechanical Fire Protection _ Electrical Other (Specify) For the above named project and that, to the best of my knowledge, such plans, computations and specifications meet the applicable provisions of the Massachusetts state building code, all acceptable engineering practices and all applicable laws and ordinances for the proposed use and occupancy. I further represent that I, or qualified professionals under my supervision, shall perform the necessary professional services and be present on the construction site on a regular and periodic basis to determine that the work is proceeding in accordance with the documents approved for the building permit and shall be responsible for the following as specified in section 116.2.2: 1. Review of shop drawings, samples and other submittals of the contractor as required by the construction contract documents as submitted for building permit, and approval for conformance to the design concept. 2. Review and approval of the quality control procedures for all code-required controlled materials. 3. Special architectural or engineering professional inspection of critical construction components requiring controlled materials or construction specified in the accepted engineering practice standards listed in Appendix B. Pursuant to section 116.4, 1 shall submit periodically, a progress report together with pertinent comments to the building inspector. Upon completion of the work, I shall submit a final report as to the satisfactory completion and readiness of the project for occupancy. SIGNATURE COMPANY NAME Gensler COMPANY ADDRESS One Beacon St, MA 02108 SUBSCRIBED AND SWORN TO BEFORE ME THIS a DAY OFu ,* 2011 MY COMMISSION EXPIRES 016)-r NOTARY P LIC ABIGAIL G. ANDERSON Notary Public Commonwealth of Massachusetts W s My Commission Expires August 25, 2017 Massachusetts- Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License License: CS 55103 Restricted to: 00 MICHAEL J HOLLAND 1126 MAIN ST S WEYMOUTH, MA 02190 i - i Expiration: 1/28/2012 Commissioner Tr#: 13123